If your child needs medical care, the law requires that you, the parent or legal guardian, give your permission. To avoid possible delay in the treatment of an ill or injured child, Florida Hospital Flagler has provided this consent form and medical history questionnaire for you to leave with the person or persons who are caring for your child during
your absence.

This signed consent form authorizes the babysitter, relative, or other persons you have named to seek immediate
medical attention for your child when it is needed, without delay. Even stepparents and grandparents must have your
authorization to seek medical care for your minor child in your absence.

In addition, the medical information requested in this form can provide some important answers for the physicians
who may be called upon to treat your child. We suggest you complete one of these forms for each of your children
when you plan to leave them in someone else’s care. It is in your best interest that your child’s healthcare needs will be met when it matters.